Standard Guide Book

Paramount Health Services and Insurance TPA Pvt. Ltd. is a leading Third Party Administrator (TPA) in the Indian insurance industry. It is operating since 2002 and is an ISO 9001:2008 certified company. It is promoted and managed by medical professionals supported by personnel from diverse backgrounds like IT, Insurance, Customer Relations etc.

Headquartered at Mumbai, Paramount has four regional offices at Delhi, Chennai, Kolkata, Bangalore and various other branch offices in major cities spread across the country.

With our experience, we have made a world of difference in the lives of over 40 million people.

On the basis of details provided by the insurance company, PHS issues a Health Card to each member covered under the policy. Please preserve this card and carry it with you at all times. It is not a credit or debit card but an Identity Card, which will identify you as the insured and will give you access to our network of Hospitals.

Besides Physical Cards we have made provision to access Electronic Card (E-Cards) on our website as well as on our mobile application. Please ensure to provide your ID No. and the name of the insurance company whenever you call on the Paramount helpline number and in all the future correspondences.

We have a call centre which is operated 24 /7 with a dedicated helpline number to provide you with the necessary information and address all your queries.

Sample queries handled by the call center are:-

Cashless

  • Procedure for cashless hospitalization
  • Confirmation of fax received for cashless hospitalization
  • Replying to Cashless Status (Additional Information Requirement, Denial of Cashless service, Issue of Authorization Letter)

Reimbursement

  • Receipt of Claim documents
  • Availability of Data
  • Claim status (Deficiency requirement, Repudiation of Claim, Clearance of claim)
  • Re-opening of claim

General

  • Cards Status
  • Provider Status (Network Hospital Status)
  • Brief on Policy Details
  • Sum Insured Details
  • Website Details
  • Claim Intimations

Claim Intimation is the process of notifying a claim to Paramount as well as the details of the Hospital - Name / Address / Contact number within the specified timelines

In case of Planned Hospitalization, Insured has to notify / intimate Paramount 48 hours prior.

In case of an Emergency Hospitalization, the Insured has to notify / intimate Paramount within 24 Hours of Hospitalization

Insured should notify the Hospitalization by calling Paramount on the helpline number (022-66 620 808).Online Intimation can also be made on our website (Intimate a claim) or/and email can be sent to claim.intimation@paramounttpa.com)

  • Insured has to arrange for the Request for Authorisation Letter (RAL) ( Cashless Request Form )from Hospital, also known as Provider ( Hospital Network ) immediately after obtaining due details from the treating doctor in the form, prescribed by the Authority. The RAL shall be sent alongwith all the relevant details in the Email/ Fax to the 24-hour authorization /cashless department of Paramount along with contact details of treating physician and the insured.
  • In case of planned admission- the RAL shall reach the authorization department of Paramount 48 hours prior to the expected date of admission.
  • The RAL form shall be duly filled, clearly mentioning ‘Yes’ or ‘No’ against all fields of the form and/or the details as required. The form shall not be sent with ‘Nil’ or blank replies.
  • Paramount guarantees payment only after receipt of RAL and the necessary medical details, and subject to Policy Terms and Conditions.

Cashless Hospitalization Documents

At the time of discharge, insured needs to sign duly filled Claim form ( Claim form )and necessary hospital documents ( Document Checklist). Hospital will submit all those documents to TPA for further processing of the Claim.

What happens at backend if Cashless is requested?

On receipt of request for Cashless hospitalization at Paramount, the Medical team at Paramount will determine whether the condition requires admission and if the treatment is covered under your health insurance policy. They will also check all the other terms and conditions of your insurance policy. Non-medical expenses will not be payable. (List of Non Payable)

  • In case coverage is available,Paramount will issue an approval to the hospital for a specified amount depending on the disease, treatment, how much you are insured for, etc. This is sent by fax and/or email (if available). The approval is called a “Preauthorization”. This preauthorization entitles you to avail cashless facility at the hospital without paying for the medical expenses. Note: Further enhancement approvals may be issued on enhancement request, subject to terms and conditions of the policy.
  • In case of any deficiency or query,an additional information letter will be sent to the Hospital. On retrieval of the required and complete information from you, the request will be processed.
  • Based on the processing of the claim, a denial or approval is executed.
  • Please note that denial of a preauthorization request is in no way to be construed as denial of treatment or denial of coverage. You can proceed with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.
  • At the time of discharge, please make sure that you check and sign the original bills and discharge summary. Please carry a copy of the signed bill, discharge summary and all your investigation reports for your records. This is for your reference and will be useful to you in the future.

What if the final bill is higher at the time of discharge?

If treatment cost is increased during hospitalization, hospital may send request to Paramount for an additional sanction. Paramount will sanction additional cashless, subject to availability of balance Sum Insured and as per policy terms and conditions.
In case of no further guarantee of payment from Paramount, Insured needs to settle the remaining amount prior to discharge.
(Please be aware of room rent eligibility. If admitted in a room higher than admissible as per the policy terms, there will be a deduction of a proportionate amount of the claim after excluding cost of medicines etc.)

How to file a claim if insured gets hospitalized in non-network hospital

Reimbursement claims can be submitted to Paramount through courier, post or in-person at any of our branches. Claim documents should be sent to Paramount as per policy guidelines issued by insurer. Claim forms can be collected from the nearest Divisional / Branch Office of the Insurance company / Paramount office or Claim forms can be downloaded from here Issuance of claim form does not mean guarantee of payment or any liability, under the policy on the part of the insurers.

The documents that you need to submit for reimbursement claims are:

  1. Original duly filled Claim form
  2. Covering letter stating your complete address, contact numbers and email address (if available), along with Schedule of Expenses
  3. Copy of the Paramount ID card or current policy copy and previous years' policy copies (if any)
  4. Original Discharge Card/ Summary
  5. Original hospital final bill
  6. Original numbered receipts for payments made to the hospital
  7. Complete breakup of the hospital bill
  8. All bills for investigations done with the respective reports
  9. All bills for medicines supported by relevant prescriptions
  10. Cancelled Cheque for quicker transfer of claim amount directly into your bank account through NEFT.

Note: You are advised to keep Photo Copy of the entire set of claim documents, submitted to us.

  1. Why are there deductions in my reimbursement claim?
  2. Charges for certain facilities are not covered by insurance co. and those expenses are deducted from the reimbursement claims.

  3. What are these expenses that are not covered?
  4. The following few expenses are not reimbursable as per standard policy conditions:

    • Registration/Admission fees
    • Telephone/Fax
    • Food & Beverages for relatives
    • Barber
    • Non- Medical expenses
    • Diet charges which are not part of the administered treatment etc. (List of Non Payable)
  5. How "National Electronic Funds Transfer” – NEFT transaction can be done?
  6. By providing the bank account particulars (including the IFSC code of your bank) you are ensuring quicker transfer of claim amount directly into your bank account.
    It is important to note that the policyholder can benefit from the quicker electronic payment systems (RTGS/NEFT) only if they are able to furnish their bank account details accurately in their claim forms. Also, kindly arrange to send a Cancelled Cheque for verification of NEFT Payment.

  7. When can my claim settlement get delayed?
  8. The claim settlement can get delayed under following conditions:

    • In case the documents are not submitted appropriately.
    • In case the document are not submitted completely.
    • In case Bank details are not provided.